MEDICARE: MRS. LISA ROSE HULTON MA SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	S160048614	WA

General Provider Information

NPI Number	:	1588817506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ROSE HULTON MA SLP

Provider Business Mailing Address
First Line	:	4560 SE INTERNATIONAL WAY, STE. 100
Second Line	:	CONSONUS HEALTHCARE SERVICES
City	:	MILWAUKIE
State	:	OR
Zip	:	97222
Country	:	US
Telephone Number	:	971-206-5200
Fax Number	:	971-206-5209

Provider Business Practice Location Address
First Line	:	2800 224TH ST
Second Line	:
City	:	DES MOINES
State	:	WA
Zip	:	98198
Country	:	US
Telephone Number	:	971-206-5200
Fax Number	:	971-206-5209

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	11/04/2008

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